Utilization Review Physician Must be Licensed in LA

In a March 11, 2015 decision by the Fifth Circuit Court of Appeal, we learn that a report issued by a utilization review physician not licensed in Louisiana is not considered “competent evidence” pursuant to Louisiana Workers’ Compensation law.

On January 6, 2013, Claimant sustained injuries to his neck, shoulder, and back, when he fell from a ladder during the course and scope of his employment. Claimant sought treatment with an orthopedist, who referred Claimant to a neurosurgeon for evaluation and recommendation of surgical options. Claimant participated in physical therapy but still complained of pain which radiated to his right leg. Accordingly, Claimant’s neurosurgeon filed a request with Louisiana Office of Workers’ Compensation Administration (“OWCA”) on LWC Form 1010 seeking authorization to proceed with a L4 laminectomy.

Based on the request’s purported failure to meet Louisiana Workforce Commission Medical Treatment Guidelines requiring “clear objective clinical evidence of radiculopathy,” the request was denied by a utilization review physician. Appealing this decision to the OWCA Medical Director, the neurologist who initially requested the surgery filed LWC Form 1009, as provided in La. R.S. 23:1203.1(J)(1). The Medical Director upheld the utilization review physician’s denial of the request for authorization. In response, Claimant submitted his disputed claim for compensation on LWC Form 1008 to the OWCA, again seeking authorization for treatment. The workers’ compensation judge determined that since the utilization review physician was not licensed in Louisiana, his utilization review was not competent evidence. The judge reversed the Medical Director’s decision to uphold the denial. She additionally ordered Employer to authorize and pay for the requested surgery and necessary medical treatment.

On appeal of the workers’ compensation judge’s decision, the Fifth Circuit affirmed the order of the workers’ compensation judge. In doing so, the Fifth Circuit recognized that La. R.S. 23:1203.1(K) establishes that the decision of the Medical Director “may be overturned when it is shown, by clear and convincing evidence, the decision . . . was not in accordance with the provisions for this Section,” which state that all authorized medical treatment decisions must be in accordance with the medical treatment schedule promulgated by the OWC. See La. R.S. 23:1203.1(1). Having established a basis for the right to overturn the decision of the Medical Director, the Fifth Circuit did just that. The Court saw no error in the trial court’s finding that the utilization physician must be duly licensed in Louisiana for his findings to be received as competent evidence. Nor did the Fifth Circuit agree with appellant that the workers’ compensation judge did not apply the correct standard of review. Accordingly, the workers’ compensation judge’s decision was affirmed. Claimant was also awarded costs, to include attorney fees.

Wilson v. Broadmoor, LLC